Undescended Testicles, Retractile Testicles,

and Testicular Torsion

This guideline, developed by Ashay Patel, D.O., in collaboration with the ANGELS team, on October
14, 2013. Last reviewed by Ashay Patel, D.O. November 4, 2016.

Key Points

Testicles should be palpable in the scrotum by 6 months of age.

When testicles are not palpable, are unable to be brought to the scrotum, or do not remain in
the scrotum by 6 months of age, a referral to a pediatric urologist is recommended for
evaluation of an undescended testicle.
Retractile testicles can be brought down to the scrotum and will remain there. If there is
difficulty with bringing the testicles to the scrotum, a referral to a pediatric urologist is
recommended.
Testicular torsion outside of the perinatal period is a surgical emergency and emergent
pediatric urology consultation is recommended.
Perinatal testicular torsion presents with a painless firm testicle noted right after birth. A
pediatric urology consultation is recommended.

Undescended Testicle

Definition
Testicle is not located in the scrotum and classified based on location
Intra-abdominal (non-palpable)
Inguinal canal
Superficial inguinal pouch

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 Upper scrotum
Ectopic (rarely)
Incidence
Term newborn 3%; at 1year 0.8%
Pre-term newborn <37 weeks 30%; at 1 year 10%
Twenty percent (20%) of undescended testicles (UDTs) are non-palpable
More common on the right side (2:1)

Monorchid or anorchid occurs 33% in child presenting with non palpable testicles.1
Occurs because of in-utero torsion or vascular event during development or
descent
Bilateral anorchia estimated to occur 1 of every 20,000 boys
Three times more likely with family history of UDT

Assessment

Birth history
Term or preterm baby
Easiest to detect in the newborn period when cremasteric reflex is weak and absence of
large amounts of fat
Majority of testicles will not descend after 6-9 months of age.
Testosterone surge at 2-4 months augments descent of UDT; 70-77% of UDTs will

descend spontaneously in first 3 months2

Seven percent (7%) of UDTs will descend spontaneously after 6 months2,3

Malignancy risk
Increased risk of malignancy compared to general population

1:1000 to 1:2500 vs. 1:100,000 4

Three times an increased risk compared to general population5

Twenty percent (20%) of testicular cancers in men with UDTs occurs in contra-lateral
descended testicle.
Orchiopexy does not change the risk of cancer, allows for self-examination.
Fertility potential
Paternity rates lower for men with history of bilateral UDTs (62%) compared to men with

unilateral UDT (89.5%) and general population (94%)6

Timing of orchiopexy helps protect fertility; testicular biopsy has shown decreasing germ

cell density starting at 1 year of age.7

Location of UDT does not significantly affect paternity; although intra-abdominal UDT

was borderline significant (p = 0.06) (90% all UDT; 83.3% intra-abdominal)8

Diagnosis
Prior history of testicles in scrotum at birth or during first year of life
Parental reporting of visualizing the testicles in the scrotum during baths
Examination in supine frog-leg position with warm hands
Start at anterior superior iliac spine and move down canal toward scrotum.

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 Once testis palpated, bring to scrotum and hold for short time to fatigue the cremasteric
muscles and then release.
An UDT will return to pre-scrotal position, a retractile testicle will remain in scrotum.
Imaging

Ultrasound, CT, and MRI not recommended for non-palpable testicles.9,10

Ultrasound may be indicated in the obese child
Laboratory testing
Not recommended for unilateral UDT or in boys with bilateral UDTs when testes were
once palpable
If bilateral non-palpable testicle and phenotypically male work up for disorders of sexual

differentiation should be performed 11

Karyotype, serum electrolytes, and hormonal profile (17-hydroxyprogesterone,
luteinizing hormone, follicle-stimulating hormone, testosterone, and
androstenedione)
Consultation with pediatric endocrinology and urology
If bilateral non-palpable testicle and no congenital adrenal hyperplasia; consider workup

for bilateral vanishing testes versus bilateral intra-adbominal testes (20x more likely)11
Consider mullerian inhibiting substance or anti-mullerian substance
Inhibin B, luteinizing hormone (LH), follicle-stimulating hormone (FSH) and
testosterone determines if testes present
If >3 months consider human chorionic gonadotropin (hCG) stimulation test (100
IU/kg) to determine if testes are present – rise in testosterone; along with FSH
and LH which should be elevated in anorchia
If unilateral UDT and severe proximal hypospadias consider possibility of disorders of

sexual differentiation.11

Management
If there is difficulty in palpating the testicle at 4-6 months of age, refer to pediatric

urologist for orchiopexy within first year.11

Orchiopexy as an outpatient surgical procedure.
Mainstay in the United States
For an UDT located in the groin, an inguinal incision is made to locate the testicle, the
hernia sac is freed from the testicle, vessels and vas deferens, and then the testicle is
positioned in the scrotum through a separate incision.
This can also be done through a scrotal incision.

Success rate for inguinal testicles is 85-91%.12

For a non-palpable testicle either a groin exploration or diagnostic laparoscopy is
performed to locate the testicle, based on surgeon preference, and the testicle is brought
down to the scrotum.
For high intra-abdominal testicles, alternative maneuvers may be used, such as
ligation of the testicular vessels (one stage or two-staged orchiopexy) to gain
additional length on the testicle.

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 Success rate is 60-80%.13
Hormonal therapy

Not recommended by the AUA.11

More common in Europe
hCG is analog to LH; mechanism for testicular descent is unknown
Dosage:
250 IU/dose in young infants
500 IU/dose up to 6 years old
1000 IU/dose >6 years
Maximum dose of 15,000 IU (closure of epiphyseal plate)
Twice a week for 5 weeks (International Health Foundation)
Success rate is 6–21% in randomized, blinded studies.
May be indicated in setting of bilateral non-palpable testicles to confirm
testicular tissue
Gonadotropin-releasing hormone (GnRH) analog to simulate pituitary to release LH and FSH
Available as a spray
Only approved to treat UDT in Europe

Retractile Testicles
Definition

Movement of the testicle from the scrotum to the suprascrotal position

Affected by the strength and contraction of the cremasteric reflex
Affected by temperature, stimulation of superficial branch of the genitofemoral nerves,
emotional anxiety
Varies with age
Reflex is weak in the neonate (testicles are larger)
Strongest in 5-10 years
Post pubertal (testicles are larger)
Can lead to ascending or acquired UDT
Hyperactive cremasteric reflex, incomplete absorption of patent process vaginalis, or
low-lying UDT

Three to thirty-three percent (3 -33%) of retractile testicles become UDT11,14,15

Greatest risk is in boys <7 years of age

Assessment

Parental history of prior testicular location

History of identifying testicle during baths or showers

Diagnosis

Examination in supine, frog-leg position with warm hands

A retractile testicle will remain in the scrotum once it is brought down and the cremaster

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 muscle is fatigued

Management

Yearly exam to confirm testicles are palpable in the scrotum11

If difficult to palpate, refer to pediatric urologist
Have parents evaluate and report if the testicles are visible in the bath

Testicular Torsion

Definition
Normal anatomy of the testicle relies on tunica vaginalis covering the anterior surface of the
testicle, epididymis; attachment of the gubernaculum (inferiorly) and scrotal wall posteriorly
preventing twisting around vascular mesentery
Lack of normal attachments can lead to twisting
Bimodal distribution
Perinatal
Ten percent (10%)
Extra-vaginal, twisting of entire spermatic cord
Pubertal
Ninety percent (90%)
Intra-vaginal, abnormal fixation of testicle/epididymis leads to twisting within the
tunica vaginalis; bell clapper deformity
Increasing testicular mass increases chance of torsion
Intermittent torsion, spontaneous twisting and untwisting of testicle

Assessment
Perinatal torsion

Seventy percent (70%) occurs prenatally.

Thirty percent (30%) occurs in previous normal testicle.16
Painless swelling and scrotal discoloration/induration

Pubertal torsion

History and physical exam critical

Acute onset of localized severe scrotal pain is 89%.17

Associated nausea and vomiting is 39%.
Prior history of ipsilateral testicular pain is 36%.
Associated trauma and recent exercise 4% and 10%, respectively
Dysuria and urgency is <5%
Prior history of orchiopexy does not rule out testicular torsion.
On exam, high riding firm tender testicle, abnormal transverse orientation of testicle, lack of
cremasteric reflex
Late findings include hydrocele, scrotal wall edema

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Torsion of appendix testis or epididymis

Comparatively, torsion of appendix testis or epididymis usually has a gradual onset; localized
pain to superior portion of testicle initially; nausea, vomiting and abdominal pain usually
absent

Diagnosis

Clinical history may help differentiate between testicular torsion and torsion of appendix
testis/epididymis.
Scrotal ultrasound maybe obtained to confirm absence of testicular torsion to avoid surgical
exploration; if ultrasound demonstrates normal blood flow then testicular torsion is very

unlikely.18

Testicular atrophy can occur as early as 4 hours if the degree of torsion is >360o, but generally
occurs after 8 hours.

Management

Perinatal torsion

Treatment is controversial; rare to salvage a unilateral neonatal torsion

In some instances delayed orchiectomy and contra-lateral orchiopexy is performed.

Pubertal torsion

If clinical concern for testicular torsion, emergent pediatric urology consultation indicated for
possible surgical exploration
If detorsion is attempted, success would be defined by immediate resolution of pain.

Testis should be turned medial to lateral

If unsuccessful, can attempt lateral to medial
Should have immediate relief of pain
Scrotal exploration with possible ipsilateral orchiopexy vs. orchiectomy of torsed testicle and
contralateral orchiopexy

This guideline was developed to improve health care access in Arkansas and to aid health care
providers in making decisions about appropriate patient care. The needs of the individual patient,
resources available, and limitations unique to the institution or type of practice may warrant
variations.

References

References
1. Levitt SB, Kogan SJ, Engel RM, Weiss RM, et al. The impalpable testis: a rational approach to
management. J Urol 1978;120(5):515-20.
2. Wenzler DL, Bloom DA, Park JM. What is the rate of spontaneous testicular descent in infants

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 with cryptorchidism? J Urol 2004;171(2):849-51.
3. Berkowitz GS, Lapinski RH, Dolgin SE, Gazella JG, et al. Prevalence and natural history of
cryptorchidism. Pediatrics 1993;92:44-9.
4. Pinczowski D, McLaughlin JK, Lackgren G, Adami HO, et al. Occurrence of testicular cancer in
patients operated on for cryptorchidism and inguinal hernia. J Urol 1991;146:1291-4.
5. Lin Lip SZ, Murchison LED, Cullis PS, Govan L, et al. A meta-analysis of the risk of boys with
isolated cryptorchidism developing testicular cancer in later life. Arch Dis Child
2013;98(1):20-6.
6. Lee PA, O’Leary LA, Songer NJ, Coughlin MT, et al. Paternity after unilateral cryptorchidism: a
controlled study. Pediatrics 1996;98:676-9.
7. McAleer IM, Packer MG, Kaplan GW, Scherz HC, et al. Fertility index analysis in
cryptorchidism. J Urol 1995;153:1255-8.
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systematic review and meta-analysis. Pediatrics 2011;127(1):119-28.
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Guideline. J. Urol. 2014; 192:337-345.
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analysis. J Urol 1995;154:1148-52.
13. Samadi AA, Palmer LS, Franco I. Laparoscopic orchiopexy: report of 203 cases with review of
diagnosis, operative technique, and lessons learned. J Endourol 2003;17:365-8.
14. Stec AA, Thomas JT, DeMarco RT, Pope JC 4th, et al. Incidence of testicular ascent in boys
with retractile testes. J Urol 2007;178:1722-5.
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recommendations. J Urol 1990;143(2):231-3.
17. Anderson JB, Williamson RC. Testicular torsion in Bristol: a 25-year review. Br J Surg
1988;75(10):988-92.
18. Altinkilic B, Pilatz A,Weidner W. Detection of normal intratesticular perfusion using color
coded duplex sonography obviates need for scrotal exploration in patients with suspected
testicular torsion. J Urol 2013;189:1853-8.